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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201653
Report Date: 05/28/2021
Date Signed: 05/28/2021 04:30:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LSA - HOME #1FACILITY NUMBER:
435201653
ADMINISTRATOR:EDWEENA DANIHERFACILITY TYPE:
740
ADDRESS:810 AGNEW RDTELEPHONE:
(408) 988-8901
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:6CENSUS: 5DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Paula KaneTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Infection Control site visit and met with Quality Assurance and Staff Development Coordinator Paula Kane.

LPA observed COVID-19 prevention posters on the front door/central entry point of the facility, along with the facility’s visitation policy. COVID-19 screening station observed in the facility’s entry way.

LPA toured the facility and patio area with staff. Bedrooms, bathrooms, kitchen, dining area, and living room observed in good repair. COVID-19 prevention and social distancing posters observed throughout the facility. All areas were free and clear of obstructions. Hand washing signs, foot operated trash cans, hand soap and paper towels were observed in each bathroom.

Medications, toxins, disinfectant supplies, and sharp objects were observed in locked cabinets and inaccessible to residents.

LPA observed an adequate supply of Personal Protective Equipment (PPE).

No deficiency cited during visit.
LPA obtained a copy of the facility's LIC 808/Mitigation Plan.

This report was reviewed with Paula Kane and a copy was provided via email.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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